Holistic Native network: integrated HIV/AIDS, substance abuse, and mental health services for Native Americans in San Francisco

Mapping the effectiveness of integrating mental health in HIV programs: a scoping review

INTRODUCTION

Mental health and substance abuse issues are increasing among HIV-positive people, and it negatively impacts health outcomes like engagement, retention in HIV care, and adherence to ART. Thus, national ART programs must include mental health management. The scoping review sought to map evidence on the efficacy of combining HIV and mental health care.

METHODS

The Arksey and O'Malley methodological framework was used to map the existing research on integrating HIV and mental health services to identify knowledge gaps. Two independent reviewers screened articles for inclusion. Studies on HIV-mental health integration were considered. We searched numerous sources, extracted data, and summarized publications by integration model and patient outcomes.

RESULTS

Twenty-nine articles met the criteria for this scoping review. Twenty-three studies were from high-income countries, with only six from low and middle-income countries in Africa (Zimbabwe 1, Uganda 3, South Africa 1, and Tanzania 1). Most of the literature discussed single-facility integration although multi-facility and integrated care through a case manager was researched as well. There was a reduction in depression, alcohol use, increased social function, decreased self-reported stigma, decreased psychiatric symptoms, and improved mood in PLHIV who received cognitive behavioral therapy in settings implementing integrated care. When providing integrated mental health services to PLHIV, healthcare workers reported feeling more comfortable discussing mental illness. Personnel in the mental health field reported less stigma and increased PLHIV referrals for mental health services due to integrated HIV and mental health care.

CONCLUSION

According to the research, integrating mental health services into HIV care improves the diagnosis and treatment of depression and other mental disorders related to substance abuse in PLHIV.

Identifying and Reducing Disparities in Mental Health Outcomes Among American Indians and Alaskan Natives Using Public Health, Mental Healthcare and Legal Perspectives

The purpose of this paper was to investigate disparities in mental healthcare delivery in American Indian/Alaska Native populations from three perspectives: public health, legal policy and mental healthcare and provide evidence-based recommendations toward reducing those disparities. Data on mental health funding to tribes were obtained from the Substance Abuse and Mental Health Services Administration. As a result of analysis of these data, vital statistics and current literature, we propose three recommendations to reduce mental health disparities. First, where possible, increase mental health funding opportunities for federally-recognized tribes. Second, model funding practices on principles of tribal self-determination. Finally, support diverse interventions that are culturally-based and culturally-appropriate.

Interventions and approaches to integrating HIV and mental health services: a systematic review

BACKGROUND

The frequency in which HIV and AIDS and mental health problems co-exist, and the complex bi-directional relationship between them, highlights the need for effective care models combining services for HIV and mental health. Here, we present a systematic review that synthesizes the literature on interventions and approaches integrating these services.

METHODS

This review was part of a larger systematic review on integration of services for HIV and non-communicable diseases. Eligible studies included those that described or evaluated an intervention or approach aimed at integrating HIV and mental health care. We searched multiple databases from inception until October 2015, independently screened articles identified for inclusion, conducted data extraction, and assessed evaluative papers for risk of bias.

RESULTS

Forty-five articles were eligible for this review. We identified three models of integration at the meso and micro levels: single-facility integration, multi-facility integration, and integrated care coordinated by a non-physician case manager. Single-site integration enhances multidisciplinary coordination and reduces access barriers for patients. However, the practicality and cost-effectiveness of providing a full continuum of specialized care on-site for patients with complex needs is arguable. Integration based on a collaborative network of specialized agencies may serve those with multiple co-morbidities but fragmented and poorly coordinated care can pose barriers. Integrated care coordinated by a single case manager can enable continuity of care for patients but requires appropriate training and support for case managers. Involving patients as key actors in facilitating integration within their own treatment plan is a promising approach.

CONCLUSION

This review identified much diversity in integration models combining HIV and mental health services, which are shown to have potential in yielding positive patient and service delivery outcomes when implemented within appropriate contexts. Our review revealed a lack of research in low- and middle- income countries, and was limited to most studies being descriptive. Overall, studies that seek to evaluate and compare integration models in terms of long-term outcomes and cost-effectiveness are needed, particularly at the health system level and in regions with high HIV and AIDS burden.

Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review

Integration of services for patients with more than one diagnosed condition has intuitive appeal but it has been argued that the empirical evidence to support it is limited. We report the findings of a systematic review that sought to identify health system factors, extrinsic to the integration process, which either facilitated or hindered the integration of services for two common disorders, HIV and chronic non-communicable diseases. Findings were initially extracted and organized around a health system framework, followed by a thematic cross-cutting analysis and validation steps. Of the 150 articles included, 67% (n = 102) were from high-income countries. The articles explored integration with services for one or several chronic disorders, the most studied being alcohol or substance use disorders (47.7%), and mental health issues (29.5%). Four cross-cutting themes related to the health system were identified. The first and most common theme was the requirement for effective collaboration and coordination: formal and informal productive relationships throughout the system between providers and within teams, and between staff and patients. The second was the need for adequate and appropriately skilled and incentivized health workers-with the right expertise, training and operational support for the programme. The third was the need for supportive institutional structures and dedicated resources. The fourth was leadership in terms of political will, effective managerial oversight and organizational culture, indicating that actual implementation is as important as programme design. A fifth theme, outside the health system, but underpinning all aspects of the system operation, was that placing the patient at the centre of service delivery and responding holistically to their diverse needs. This was an important facilitator of integration. These findings confirm that integration processes in service delivery depend substantially for their success on characteristics of the health systems in which they are embedded.

Suicide and Suicide Prevention among Inuit in Canada

Inuit in Canada have among the highest suicide rates in the world, and it is primarily among their youth. Risk factors include known ones such as depression, substance use, a history of abuse, and knowing others who have made attempts or have killed themselves, however of importance are the negative effects of colonialism. This took place for Inuit primarily during the government era starting in the 1950s, when Inuit were moved from their family-based land camps to crowded settlements run by white men, and children were removed from their parents and placed into residential or day schools. This caused more disorganization than reorganization. The most negative effect of this colonialism/imperialism for Inuit has been on their family and sexual relationships. Many Inuit youth feel alone and rejected. Suicide prevention has been taking place, the most successful being community-driven programs developed and run by Inuit. Mental health factors for Indigenous peoples are often cultural. It is recommended that practitioners work with the community and with Inuit organizations. Empowered communities can be healing.

HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic

From the early days of the HIV epidemic, Indigenous peoples were identified as a population group that experiences social and economic determinants-including colonialism and racism-that increase exposure to HIV. There are now substantial disparities in HIV rates between Indigenous and non-Indigenous peoples in some countries. We conducted a comprehensive literature review to assess the evidence on HIV-related behaviors and determinants in four countries-Australia, Canada, New Zealand and the United States-in which Indigenous peoples share important features of colonization and marginalization. We identified 107 articles over more than 20 years. The review highlights the determinants of HIV-related behaviors including domestic violence, stigma and discrimination, and injecting drug use. Many of the factors associated with HIV risk also contribute to mistrust of health services, which in turn contributes to poor HIV and health outcomes among Indigenous peoples.

Crystalizing the role of traditional healing in an urban Native American health center

A needs assessment surveying American Indians and Alaska Natives (AIs/ANs) at an AI/AN health center in the Midwestern United States was conducted, with an emphasis on traditional Native healing. Data from this study included qualitative material from interviews of community members (N = 27; age 12-82) and service providers (N = 11; age 26-70). Respondents emphasized the path to wellness includes physical, spiritual and mental health and that traditional healing can restore various imbalances. Furthermore, traditional healing was considered a complement to Western medicine. Third, traditional medicine as a tool in healthcare settings was conceptualized on a continuum.

Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study

Background

Cultural interventions offer the hope and promise of healing from addictions for Indigenous people.^a However, there are few published studies specifically examining the type and impact of these interventions. Positioned within the Honouring Our Strengths: Culture as Intervention project, a scoping study was conducted to describe what is known about the characteristics of culture-based programs and to examine the outcomes collected and effects of these interventions on wellness.

Methods

This review followed established methods for scoping studies, including a final stage of consultation with stakeholders. The data search and extraction were also guided by the “PICO” (Patient/population, Intervention, Comparison, and Outcome) method, for which we defined each element, but did not require direct comparisons between treatment and control groups. Twelve databases from the scientific literature and 13 databases from the grey literature were searched up to October 26, 2012.

Results

The search strategy yielded 4,518 articles. Nineteen studies were included from the United States (58%) and Canada (42%), that involved residential programs (58%), and all (100%) integrated Western and culture-based treatment services. Seventeen types of cultural interventions were found, with sweat lodge ceremonies the most commonly (68%) enacted. Study samples ranged from 11 to 2,685 clients. Just over half of studies involved quasi-experimental designs (53%). Most articles (90%) measured physical wellness, with fewer (37%) examining spiritual health. Results show benefits in all areas of wellness, particularly by reducing or eliminating substance use problems in 74% of studies.

Conclusions

Evidence from this scoping study suggests that the culture-based interventions used in addictions treatment for Indigenous people are beneficial to help improve client functioning in all areas of wellness. There is a need for well-designed studies to address the question of best relational or contextual fit of cultural practices given a particular place, time, and population group. Addiction researchers and treatment providers are encouraged to work together to make further inroads into expanding the study of culture-based interventions from multiple perspectives and locations.

A typology of primary care workforce innovations in the United States since 2000

PURPOSE

Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices.

METHODS

Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000. Expert consultants identified additional articles that would not show up in a regular computerized search. Full texts of relevant articles were read and matrices for sorting articles were developed. Each article was reviewed and assigned to one of 18 cells in the matrices. Articles within each cell were then read again to identify patterns and develop an understanding of the full spectrum of workforce innovation within each category.

RESULTS

This synthesis led to the development of a typology of workforce innovations represented in the literature. Many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. Most of these sought to minimize the impact on the existing practice roles and functions, particularly that of physicians. The synthesis also identified recent innovations which attempted to fundamentally transform the existing practice, with transformation being defined as a change in practice members' governing variables or values in regard to their workforce role.

CONCLUSIONS

Most conceptualizations of the primary care workforce described in the literature do not reflect the level of innovation needed to meet the needs of the burgeoning numbers of patients with complex health issues, the necessity for roles and identities of physicians to change, and the call for fundamentally redesigned practices. However, we identified 5 key workforce innovation concepts that emerged from the literature: team care, population focus, additional resource support, creating workforce connections, and role change.

Patterns of HIV and mental health service integration in New York State

The Affordable Care Act (ACA) creates incentives to coordinate primary care, mental health (MH) care, and addiction services. Integration of clinical HIV and MH services has been shown to improve quality of life and physical and MH of people living with HIV/AIDS. However, few studies have investigated the practice of service integration systematically. We examined the practice patterns of 515 direct service providers in New York State who received training about HIV MH between May 2010 and July 2012. We sought to identify provider and treatment setting characteristics associated with an integrated spectrum of care. Using factor analysis and linear modeling, we found that patterns of service integration varied by type of health-care setting, service setting location, providers' HIV caseload, and the discipline of the provider describing the direct services. Understanding the existing capacities of clinicians providing care in a variety of settings throughout New York will help to guide staffing and linkage to enhance HIV MH service integration as significant shifts in the organization of health care occur.

IMB model in practice: social workers' intentions to change their practice following HIV mental health training

We identified predictors of social workers' intentions to integrate HIV and mental health care following Information, Motivation, Behavior Change (IMB) model trainings. We used multiple logistic regression analysis to understand applicability of the IMB model in promoting practice change. Significantly greater intentions to integrate care were found among participants who perceived an increase in knowledge (twofold) or who felt more comfortable (nearly fourfold) or capable (nearly fivefold) working with HIV-infected clients. Training that enhances knowledge and motivation enhanced social workers' intentions to change clinical practice. IMB-based training builds social worker capacity to deliver integrated care. The results support utility of the IMB model in enhancing HIV care.

Holistic System of Care: a ten-year perspective

The Holistic System of Care for Native Americans in an Urban Environment is a community-focused intervention that provides behavioral health care, promotes health, and prevents disease. This approach is based on a community strategic planning process that honored Native American culture and relationships. Substance abuse, mental illness, homelessness, poverty, crime, physical illness, and violence are symptoms of historical trauma, family dysfunction, and spiritual imbalance. The holistic model links treatment, prevention, and recovery. The link between prevention and treatment is early intervention. Peer support is the link between treatment and recovery. Recovering individuals serve as role models linking recovery to prevention. Culture and spirituality build a strong and resilient foundation for recovery. This article documents the effectiveness of the holistic model over a ten-year period that it has been implemented at the Family & Child Guidance Clinic of the Native American Health Center in the San Francisco Bay Area. The holistic model has produced statistically significant reductions in substance abuse among adult Native American women, men, reentry, and homeless populations; reductions in substance abuse among Native American adolescents; reductions in HIV/AIDS high-risk behavior among Native American men, women, and adolescents; and decreases in acting out behavior among Native American severely emotionally disturbed children.

Holistic system of care: evidence of effectiveness

The Native American Health Center provides substance use and mental health services for urban American Indians and Alaska Natives (AIs/ANs) utilizing a culturally based holistic system of care (HSOC). Substance use prevention, treatment, and recovery services emphasize traditional AI/AN healing practices alongside evidence-based practices. This article describes the HSOC approach and provides preliminary findings from an outcome evaluation. Participants in outpatient and residential treatment were interviewed at baseline and 6-month follow-up with a standardized assessment tool (n = 490). The sample we composed of 86% AI/AN, 70% females, 30% males, and was entirely urban. Decreases in substance use and its related consequences were evident in both modalities but were most pronounced in residential treatment. Study's limitations and implications are included.

Cultural leverage: interventions using culture to narrow racial disparities in health care

The authors reviewed interventions using cultural leverage to narrow racial disparities in health care. Thirty-eight interventions of three types were identified: interventions that modified the health behaviors of individual patients of color, that increased the access of communities of color to the existing health care system, and that modified the health care system to better serve patients of color and their communities. Individual-level interventions typically tapped community members' expertise to shape programs. Access interventions largely involved screening programs, incorporating patient navigators and lay educators. Health care interventions focused on the roles of nurses, counselors, and community health workers to deliver culturally tailored health information. These interventions increased patients' knowledge for self-care, decreased barriers to access, and improved providers' cultural competence. The delivery of processes of care or intermediate health outcomes was significantly improved in 23 interventions. Interventions using cultural leverage show tremendous promise in reducing health disparities, but more research is needed to understand their health effects in combination with other interventions.

Within the Hidden Epidemic: Sexually Transmitted Diseases and HIV/AIDS Among American Indians and Alaska Natives

OBJECTIVES

To review the epidemiology, research, and prevention programs for sexually transmitted diseases in American Indians and Alaska Natives (AI/ANs).

STUDY DESIGN

We reviewed the current national and regional trends in sexually transmitted diseases (STDs) for AI/ANs from 1998-2004, peer-reviewed studies from January 1996, through May 2006, and reports, unpublished documents, and electronic resources addressing AI/AN STD prevention and control.

RESULTS

STD prevalence among AI/ANs remains high. For example, the case rate of C. trachomatis in the North Central Plains AI/AN populations is 6 times the overall US rate. Trends for C. trachomatis also show sustained increases. Little research exists on STDs for this population, and most is focused on HIV/AIDS. Fear of compromised confidentiality, cultural taboos, and complex financial and service relationships inhibit effective surveillance, prevention, and management.

CONCLUSIONS

Recommendations for STD control in this population include improved local surveillance and incorporation of existing frameworks of health and healing into prevention and intervention efforts. Research defining the parameters of cultural context and social epidemiology of STDs is necessary.

Effectiveness of different models of case management for substance-abusing populations

Case management has been implemented in substance abuse treatment to improve (cost-) effectiveness, but controversy exists about its potential to realize this objective. A systematic and comprehensive review of peer-reviewed articles (n = 48) published between 1993 and 2003 is presented, focusing on the effects of different models of case management among various substance-abusing populations. Results show that several studies have reported positive effects, but only some randomized and controlled trials have demonstrated the effectiveness of case management compared with other interventions. Longitudinal effects of this intervention remain unclear. Although no compelling evidence was found for the effectiveness of case management, some evidence is available about the (differential) effectiveness of intensive case management and assertive community treatment for homeless and dually-diagnosed substance abusers. Strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Most positive effects concern reduced use of inpatient services and increased utilization of community-based services, prolonged treatment retention, improved quality of life, and high client satisfaction. Outcomes concerning drug use and psychosocial functioning are less consistent, but seem to be mediated by retention in treatment and case management. Further research is required to learn more about the extent of the effects of this intervention, how long these are sustained and what specific elements cause particular outcomes.